Private Schools

CEO C_13 LEA Meal Counting and Claiming Form_Non-CEO

OMB Clearance # 0584-XXXX

Expiration Date: XX/XX/20XX

Community Eligibility Option Evaluation

LEA Meal Counting and Claiming Form—Non-CEO Schools

Section I. LEA Meal Count Verification—Target Day for Sampled School(s)

LEA Name: ____________________________________________LEA ID: ________________

Date Data Collected: ___ / ___ / _______ Data Collector: ____________________

MM DD YYYY

INTERVIEWER NOTE: Introduce yourself to the respondent. Remind them of the reason for your visit (refer to advance letter if needed). Review informed consent paragraph from the advance letter; and give them a copy of this letter.

Instructions: For each school sampled in the LEA, complete the information below. Fill in the school reported total meal counts as recorded by the LEA.

School 1

S

Target Day is the same day that the interviewer collected meal count verification data in the school.

chool Name: ______________________________________School ID: _________________

Target Day: ___ / ___ / _______

MM DD YYYY

Meal Count Totals: Reported to LEA by school

Breakfast: Free: Lunch: Free: _

Reduced: Reduced: _

Paid: Paid: _

Total: Total: _

Student Information for School

Collect the most recent enrollment and average daily attendance and indicate what period of time it covers.

Total enrolled students:________________ Reference Month/Week/Day:_________________

Average daily attendance:______________ Reference Month/Week/Day:_________________

Students approved for Free meals:__________ Reference Month/Week/Day:__________

Students approved for reduced price meals:_______ Reference Month/Week/Day:__________

School 2

S

Target Day is the same day that the interviewer collected meal count verification data in the school.

chool Name: ______________________________________School ID: _________________

Target Day: ___ / ___ / _______

MM DD YYYY

Meal Count Totals: Reported to LEA by school

Breakfast: Free: Lunch: Free: _

Reduced: Reduced: _

Paid: Paid: _

Total: Total: _

Student Information for School

Collect the most recent enrollment and average daily attendance and indicate what period of time it covers.

Total enrolled students:________________ Reference Month/Week/Day:_________________

Average daily attendance:______________ Reference Month/Week/Day:_________________

Students approved for Free meals:__________ Reference Month/Week/Day:__________

Students approved for reduced price meals:_______ Reference Month/Week/Day:__________

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB number. The valid OMB control number for this information collection is 0584-XXXX. The time required to complete this information collection is estimated to average 60 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Food and Nutrition Service, Office of Research and Analysis, 3101 Park Center Drive, Alexandria, Virginia 22302.

School 3

S

Target Day is the same day that the interviewer collected meal count verification data in the school.

chool Name: ______________________________________School ID: _________________

Target Day: ___ / ___ / _______

MM DD YYYY

Meal Count Totals: Reported to LEA by school

Breakfast: Free: Lunch: Free: _

Reduced: Reduced: _

Paid: Paid: _

Total: Total: _

Student Information for School

Collect the most recent enrollment and average daily attendance and indicate what period of time it covers.

Total enrolled students:________________ Reference Month/Week/Day:_________________

Average daily attendance:______________ Reference Month/Week/Day:_________________

Students approved for Free meals:__________ Reference Month/Week/Day:__________

Students approved for reduced price meals:_______ Reference Month/Week/Day:__________

School 4

S

Target Day is the same day that the interviewer collected meal count verification data in the school.

chool Name: ______________________________________School ID: _________________

Target Day: ___ / ___ / _______

MM DD YYYY

Meal Count Totals: Reported to LEA by school

Breakfast: Free: Lunch: Free: _

Reduced: Reduced: _

Paid: Paid: _

Total: Total: _

Student Information for School

Collect the most recent enrollment and average daily attendance and indicate what period of time it covers.

Total enrolled students:________________ Reference Month/Week/Day:_________________

Average daily attendance:______________ Reference Month/Week/Day:_________________

Students approved for Free meals:__________ Reference Month/Week/Day:__________

Students approved for reduced price meals:_______ Reference Month/Week/Day:__________

School 5

S

Target Day is the same day that the interviewer collected meal count verification data in the school.

chool Name: ______________________________________School ID: _________________

Target Day: ___ / ___ / _______

MM DD YYYY

Meal Count Totals: Reported to LEA by school

Breakfast: Free: Lunch: Free: _

Reduced: Reduced: _

Paid: Paid: _

Total: Total: _

Student Information for School

Collect the most recent enrollment and average daily attendance and indicate what period of time it covers.

Total enrolled students:________________ Reference Month/Week/Day:_________________

Average daily attendance:______________ Reference Month/Week/Day:_________________

Students approved for Free meals:__________ Reference Month/Week/Day:__________

Students approved for reduced price meals:_______ Reference Month/Week/Day:__________

School 6

S

Target Day is the same day that the interviewer collected meal count verification data in the school.

chool Name: ______________________________________School ID: _________________

Target Day: ___ / ___ / _______

MM DD YYYY

Meal Count Totals: Reported to LEA by school

Breakfast: Free: Lunch: Free: _

Reduced: Reduced: _

Paid: Paid: _

Total: Total: _

Student Information for School

Collect the most recent enrollment and average daily attendance and indicate what period of time it covers.

Total enrolled students:________________ Reference Month/Week/Day:_________________

Average daily attendance:______________ Reference Month/Week/Day:_________________

Students approved for Free meals:__________ Reference Month/Week/Day:__________

Students approved for reduced price meals:_______ Reference Month/Week/Day:__________

Section II. LEA Reimbursement Claim Verification

A. Target Week or Month: ___ / ___ / _______ to ___ / ___ / _______

MM DD YYYY MM DD YYYY

B. Recording Meals Reported to LEA and Claimed by LEA

Which schools?

• IF LEA submits consolidated claim to State (i.e. all schools combined), complete table for all schools in LEA. If more than 15 schools in LEA, photocopy necessary records and complete table off site

• IF LEA submits claims by individual school to the State, complete table for only sampled schools.

What’s recorded?

• Write in school names in column 1. Enter meal counts in columns 2 and 4 as reported to the LEA by the school.

• If the LEA submits claims to the State per individual schools, record what the LEA claimed in columns 3 and 5 for each individual school.

• If the LEA submits consolidated claims to the states, record this consolidated claim in columns 3 and 5 in the last row of the table.

Comparing counts/claims:

• For LEAs that submit claims for individual schools: Compare column 2 to column 3 and column 4 to column 5 for each school.

• For LEAs that submit consolidated claims, compare columns 2 to column 3 and column 4 to column 5 for the totals only (last row of table).

If you find any discrepancies, check the box in column 6, and include any explanations or comments from the LEA in section C.

1	2	3	4	5	6
SCHOOL NAME	BREAKFASTS Reported to LEA by School	BREAKFASTS Claimed by LEA	LUNCHES Reported to LEA by School	LUNCHES Claimed by LEA	DISCREPANCY (Comment in section C)
School #1 ____________________________________________________________________________________________________________________	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	
School #2 ____________________________________________________________________________________________________________________	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	
School #3 ____________________________________________________________________________________________________________________	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	
School #4 ____________________________________________________________________________________________________________________	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	
School #5 _____________________________________________________________________________________________________________________	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	
School #6 ____________________________________________________________________________________________________________________	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	
School #7 ____________________________________________________________________________________________________________________	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	
School #8 ____________________________________________________________________________________________________________________	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	
School #9 ____________________________________________________________________________________________________________________	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	
School #10 ____________________________________________________________________________________________________________________	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	
School #11 ____________________________________________________________________________________________________________________	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	
School #12 ____________________________________________________________________________________________________________________	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	
School #13 ____________________________________________________________________________________________________________________	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	
School #14 ____________________________________________________________________________________________________________________	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	
School #15 ____________________________________________________________________________________________________________________	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	
School #16 ____________________________________________________________________________________________________________________	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	
School #17 ____________________________________________________________________________________________________________________	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	
School #18 ____________________________________________________________________________________________________________________	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	
Record/calculate totals in rows below for LEAs with consolidated claims only
TOTALS (For LEAs with consolidated claims, add meal counts for all schools in column 2 and record meals claimed by the LEA in column 3 )	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	___________ Free ___________ Reduced ___________ Paid ___________ Total	

C. Discrepancies

Record any discrepancies between counts provided by the school vs. claimed by the LEA. Ask LEA about the discrepancy and record any explanations. There may be differences because of an LEA error, or because the LEA is correcting an error made by the school. Ask to see the LEA’s records/notes regarding the correction or claim. Record notes or comments below.

SCHOOL	Describe the discrepancy	LEA notes, comments, or explanation
School #_____	 breakfast  lunch
School #_____	 breakfast  lunch
School #_____	 breakfast  lunch
School #_____	 breakfast  lunch
School #_____	 breakfast  lunch
School #_____	 breakfast  lunch
School #_____	 breakfast  lunch
School #_____	 breakfast  lunch
School #_____	 breakfast  lunch

LEA Meal Counting and Claiming Form—Non-CEO Schools 1